relatively denser fibrous bond between the dura mater and the inner table
of the skull in older individuals. (b)There is, however, a high incidence of
subdural hematomas in elderly patients. As the brain mass decreases in size
with age, there is greater stretching and tension of the bridging veins that
pass from the brain to the dural sinuses. (c)In the elderly, diminished elas-
ticity of the lungs can lead to a reduction in pulmonary compliance and in
the ability to cough effectively, resulting in an increased risk for nosocomial
gram-negative pneumonia. Geriatric patients are thus more susceptible to
the development of hypoxia and respiratory infections following trauma.
(d)The most common cervical spine fractures in this age group are upper
cervical, particularly fractures of the odontoid, not lower C6 fractures.
150.The answer is b. (Tintinalli, pp 1715-1716.)The evaluation of
patients with pelvic fracturesbegins with the primary trauma survey
(ABCs). Fractured pelvic bones bleed briskly and can lacerate surrounding
soft tissues and disrupt their extensive arterial and venous networks. Hem-
orrhage is a common cause of death in patients with pelvic injuries. Bleeding
in the retroperitoneum can accommodate up to 4 L of blood. Most pelvic
bleeding is from the fractures and low-pressure sacral venous plexus. In the
ED, a stabilizercan be applied to the pelvis to help control the hemorrhage.
Once an abdominal source of bleeding is ruled out as a source of hypoten-
sion, the patient should undergo pelvic angiography with embolization of
bleeding vessels.The patient should also be resuscitated with packed RBCs
until the bleeding is controlled.
(a)It is often difficult to discern peritoneal bleeding from pelvic bleed-
ing as a cause of hypotension. A positive FAST examination or DPL in the
setting of hypotension requires that the patient undergo exploratory laparo-
tomy to control peritoneal hemorrhage. If a pelvic source of bleeding is also
suspected, some facilities are able to perform pelvic angiography in the same
OR suite. (c)If the patient was stable, he would undergo a CT scan to bet-
ter evaluate for internal injuries. However, in the setting of hypotension, the
patient requires definitive therapy. (d)A pericardiocentesis is rarely used in
the acute trauma setting and is reserved for the treatment of pericardial tam-
ponade.(e)A retrograde urethrogram is performed when there is suspicion
for a urethral injury in the stable patient.
151.The answer is b.(Tintinalli, pp 1613-1614.)Blunt trauma is the
most common mechanism of injury seen in the United States. The forces
exerted on the abdomen put all of the organs at risk for injury. Motor vehicle
166 Emergency Medicine